The effectiveness of antibiotic cement-coated nails in post-traumatic femoral and tibial osteomyelitis - comparative analysis of custom-made versus commercially available nails

[Intramedullary nailing of coated and uncoated nails in infected tibial pseudarthrosis : Results of a retrospective examination of 56 patients]

BACKGROUND

In surgery for sepsis it is a well-established principle that no internal osteosynthetic material should be implanted in cases of chronic osteomyelitis. Therefore, the surgical treatment with intramedullary nails is so far used only rarely in cases of chronic osteomyelitis.

OBJECTIVE

This study analyzed whether the implantation of tibial intramedullary nails is an effective treatment for chronic osteomyelitis and how high is the rate of reinfection.

MATERIAL AND METHODS

A retrospective analysis of patients with an infected pseudarthrosis of the tibia in whom a gentamycin-coated nail (ETN) or an uncoated tibial intramedullary nail (UCN) was implanted between December 2011 and December 2019 was carried out. The preoperative, perioperative and postoperative results were evaluated.

RESULTS

During the study period 29 patients received a UCN and 27 patients received an ETN. Of the patients 95% (n = 53) had been previously unsuccessfully treated with external fixation. Postoperative complications occurred in 45% of the patients and more often in the ETN group (48% vs. 41%). Reexacerbation of the infection occurred in 20 patients and more frequently in the UCN group (38% vs. 33%). The nonunion already showed a bony consolidation at the time of the exacerbation in 10 patients (50%). At the end of the follow-up a consolidation was present in 48 patients (86%), more frequently in the UCN group (90% vs. 78%). Of the patients 50 (89%) reached full weight bearing without any differences between the groups.

CONCLUSION

Despite a relatively high a rate of postoperative complications the risk of reinfection was acceptable with good functional and radiological results. The main general advantages of nailing are without doubt the high primary stability, the implantation with preservation of the soft tissue and the improved wearing comfort for patients.

Management of Infected Tibial Nonunion: Combining Synthetic Bone Grafting with Continuous Local Antibiotic Perfusion (CLAP)

BACKGROUND Infection control and reconstruction of bone and soft tissue are essential for treating infected nonunion. Continuous local antibiotic perfusion (CLAP) is a drug delivery system that continuously delivers antibiotics at the required concentration, area, and duration. This case report describes the instance of infected nonunion in which infection eradication and bone union were achieved using CLAP and synthetic bone grafting while retaining the implant. CASE REPORT The case was a 31-year-old woman with an infected nonunion. After she underwent osteosynthesis using nail for open fractures of tibia and fibula, bone union remained unachieved, and she exhibited skin defects and draining of pus. Following the removal of the infected granulation tissue from the bone defects, 2 bone marrow needles, serving as intramedullary antibiotic perfusion (iMAP) pins, were inserted into the medullary cavity tibia. A double-lumen tube was placed in the subcutaneous pocket as the intra-soft tissue antibiotic perfusion (iSAP) tube. No bone mobility was observed around the bone defect and nail, and replacement of the implant was not necessary. Beta-tricalcium phosphate was transplanted to the bone defect, and negative pressure wound therapy was applied. Gentamicin was injected continuously through iMAP and iSAP. Finally, the infection was eradicated, and cortical bone bridging was observed without additional surgery or adverse effects. CONCLUSIONS CLAP emerges as a viable treatment option for infected nonunion, as it enables the delivery of antibiotics at a concentration sufficient for infection control while providing the surgeon with flexibility to design the area, dosage, and duration of antibiotic delivery.

Fracture related infection in open tibial fractures

Open tibia fractures frequently occur following high-energy trauma. Contamination of the fracture site combined with limited soft tissue coverage and blood supply means that these open fractures are associated with a high rate of complications, including fracture related infection (FRI). FRI is associated with lowered patient outcomes and requires early recognition and appropriate surgical and medical management. The current evidence on FRI after open tibial fractures largely is limited to case series, small retrospective cohort studies and expert opinion. Recent expert consensus has produced guidelines with the aim of standardising care for these patients. This review summarises the current management strategies employed in treating FRI following open tibial fractures and where possible the evidence behind them.

Antibiotic impregnated cement coated intramedullary nail (ACCIN) using bronchoscopy tubing: technical tips, case series and a review of the literature

Antibiotic impregnated cement coated intramedullary nails (ACCINs) have been used in clinical practice for many years and have been shown to help eradicate infection in tibial osteomyelitis while providing stability. We present a novel technique for preparation using bronchoscopy tubing, as well as technical tips and a review of the literature, for ease of preparation and potential subsequent retrieval.

Antibiotic cement-coated rigid locked nails in infected femoral and tibial nonunion. Reoperation rates of commercial versus custom-made nails

INTRODUCTION

The objective of this study is to assess bone union, infection control, and reoperation rates in a series of patients with infected femoral or tibial nonunion treated with antibiotic-cement-coated rigid nails and to compare the results obtained with custom-made nails versus commercial nails.

METHODS

We retrospectively analyzed a series of consecutive patients with infected nonunion of the femur or the tibia treated with antibiotic-cement-coated rigid nails between January 2010 and 2020. We assessed patients' distinctive characteristics, initial injury, type of nail used (custom-made nail with vancomycin or commercial nail with gentamicin), success rate (bone union + infection control), reoperation rate, and failure rate. Comparative analyses were conducted between reoperated and non-reoperated patients regarding the type of nail used. A multivariate regression analysis was performed to assess the risk variables that impacted reoperation rates.

RESULTS

We included 54 patients with 22 (40.74%) infected femoral nonunions and 32 (59.25%) tibial nonunions, who were treated with 38 (70.37%) custom-made antibiotic-cement coated nails and 16 (29.62%) commercial nails. Bone union and infection control were achieved in 51 (94.44%) cases. The reoperation rate was 40.74% (n = 22), and the failure rate was 5.55% (n = 3). The use of custom-made nails was associated with a higher risk of reoperation (Odds Ratio 4.71; 95% Confidence Interval 1.10 - 20.17; p = 0.036).

CONCLUSION

Antibiotic-cement-coated nails reached a 94.44% success rate. Nails manufactured in the OR coated with vancomycin cement were associated with a higher risk of reoperation than commercial nails loaded with gentamicin cement.

LEVEL OF EVIDENCE

III comparative, observational, non-randomized.

Effectiveness of antibiotic-coated intramedullary nails for open tibia fracture infection prevention. A systematic review and meta-analysis

INTRODUCTION

Open Tibia fractures are associated with high rates of Fracture Related Infection (FRI). Given the negative outcomes and increased costs related to the latter, several prophylactic local antibiotic delivery methods have been proposed, aiming to decrease the FRI rate. Our objective with this study was to determine the effectiveness of antibiotic-coated intramedullary nails for open tibia FRI prevention.

PATIENTS AND METHODS

We conducted a PRISMA compliant systematic review and meta-analysis. Queries were performed on Embase, PubMed, Lilacs and Cochrane data libraries. Seventeen studies were included for qualitative analysis and 2 studies were amenable for meta-analysis.

RESULTS

Global infection, deep infection and non-union rates were 8.4%, 5.4% and 3.7% in the antibiotic-coated nail group and 22%, 14% and 14% in the non-antibiotic-coated nail group respectively. The meta-analysis showed a protective trend that favored the antibiotic-coated nail group although it didn't achieve statistical significance: deep infection Relative Risk (RR) (RR = 0.17 CI95% [0.02 - 1.31]); global infection RR = 0.36 CI95% [0.10 - 1.35]) and non-union (RR = 0.14 CI95% [0.02 - 1.22]), CONCLUSIONS: Our findings suggest a favorable trend towards antibiotic-coated nail, with decreased risk of global infection, deep infection and non-union as compared to non-antibiotic-coated nail in patients with open tibia fractures. Nonetheless, higher level evidence studies are required to confirm our findings.

Antibiotic coated nails: Rationale, development, indications and outcomes

The concept of antibiotic-coated implants, mainly coated intramedullary nails, has become increasingly used for the treatment of fracture related infections. After a long period of hand-made implants, commercially fabricated implants combine several benefits. Antibiotic-coated nails constitute a solid treatment option for unstable diaphyseal infections with fractures or non-unions. They release high concentrations of antibiotics locally, while retaining reduction and providing axial stability. This review aims to provide an overview about the background, the development, the indications, the treatment strategies and the outcomes of antibiotic-coated intramedullary nails.

Individual and commercially available antimicrobial coatings for intramedullary nails for the treatment of infected long bone non-unions - a systematic review

The treatment of infected non-unions of the femur and the tibia remains difficult and requires control of the infection and successful bone healing. Antimicrobial coating of intramedullary nails promises both infection control and stabilization for subsequent bone healing. Both results for custom-made and commercially available antimicrobial coating for intramedullary nails have been published in the past mainly consisting of retrospective case series. The purpose of this work is to review the published literature on techniques and clinical outcome of antimicrobial coatings for intramedullary nails for the treatment of infected long bone non-unions. A systematic literature research in Medline, PubMed, Embase and Cochrane Library was performed in accordance to the PRISMA guidelines. Articles reporting on antimicrobial-coated intramedullary nails for the treatment of infected long bone non-unions were eligible for inclusion. In total, 22 publications were found reporting on 506 infected non-unions of the tibia and femur treated with an antimicrobial-coated nail. Most of them consisted of retrospective case series (72.7%). 469 and 37 patients were treated with an individual antibiotic-loaded PMMA-coating and commercially available gentamicin-coating for intramedullary nails, respectively. The overall infection eradication rate was 90.0% (range 68.7-100%) and the bone consolidation rate was 85.5% (range 57.9-100%). Coating specific side effects were not reported. In conclusion, the treatment of infected long bone non-unions with antimicrobial-coated nails is associated with a high infection control and bone consolidation rate and seems to be a reasonable treatment options with minimal side effects. However, scientific quality of the publications is low and randomized controlled trials are needed.

Fracture-related infection

Musculoskeletal trauma leading to broken and damaged bones and soft tissues can be a life-threating event. Modern orthopaedic trauma surgery, combined with innovation in medical devices, allows many severe injuries to be rapidly repaired and to eventually heal. Unfortunately, one of the persisting complications is fracture-related infection (FRI). In these cases, pathogenic bacteria enter the wound and divert the host responses from a bone-healing course to an inflammatory and antibacterial course that can prevent the bone from healing. FRI can lead to permanent disability, or long courses of therapy lasting from months to years. In the past 5 years, international consensus on a definition of these infections has focused greater attention on FRI, and new guidelines are available for prevention, diagnosis and treatment. Further improvements in understanding the role of perioperative antibiotic prophylaxis and the optimal treatment approach would be transformative for the field. Basic science and engineering innovations will be required to reduce infection rates, with interventions such as more efficient delivery of antibiotics, new antimicrobials, and optimizing host defences among the most likely to improve the care of patients with FRI.

Antibiotic cement-coated intramedullary nail is cost-effective for the initial treatment of GAⅢ open tibia fractures

OBJECTIVE

To evaluate the cost-effectiveness of antibiotic cement-coated intramedullary nails (IMN) in the initial management of Gustilo-Anderson type Ⅲ (GAIII) open tibia fractures.

METHODS

A break-even equation was used to analyze the costs associated with antibiotic cement-coated IMN and postoperative infection following GAⅢ open tibia fractures. This equation produced a new infection rate, which defines what percentage the antibiotic coated IMN needs to decrease the initial infection rate for its prophylactic use to be cost-effective. The postoperative infection rate used for calculations was 30%, a value established in current literature for these fracture types (6-33%). The institutional costs associated with a single operative debridement and resultant inpatient stay and treatment were determined. A sensitivity analysis was conducted to demonstrate how various total costs of infection and different infection rates affected the break-even rate, the absolute risk reduction (ARR), and the number needed to treat (NNT).

RESULTS

Financial review yielded an average institutional cost of treating a postoperative infection to be $13,282.85. This number was inclusive of all procedures during an inpatient stay. The added cost of the antibiotic coated implant to the hospital is $743.42. Utilizing the break-even formula with these costs and a 30% initial infection rate, antibiotic coated IMN was economically viable if it decreased infection rate by 0.056% (NNT = 1,785.714).

CONCLUSION

This break-even analysis model suggests the initial use of an antibiotic coated IMN in the setting of GAⅢ open tibia fractures is cost-effective.